The nurse is collecting data from a caregiver, and the caregiver states that the child has had a “strawberry-colored tongue.” The nurse recognizes this as a manifestation of which disorder?

Hemophilia.

Congestive heart failure.

Kawasaki disease.

Rheumatic fever.

Answer and Explanation

The Correct Answer is C

Choice A reason: Hemophilia causes bleeding issues, not a strawberry tongue, which is a mucosal symptom. Kawasaki disease’s characteristic tongue appearance matches the description, making this unrelated and incorrect compared to the specific disorder associated with the child’s reported tongue manifestation in the assessment.

Choice B reason: Congestive heart failure affects cardiac function, not oral mucosa, and doesn’t cause a strawberry tongue. Kawasaki disease is the condition linked to this symptom, making this irrelevant and incorrect for the nurse’s recognition of the child’s tongue appearance in data collection.

Choice C reason: A strawberry tongue, with a red, bumpy appearance, is a hallmark of Kawasaki disease, often seen with fever and rash. This aligns with pediatric infectious disease criteria, making it the correct disorder the nurse recognizes based on the caregiver’s description of the child’s tongue.

Choice D reason: Rheumatic fever may cause oral symptoms but not a classic strawberry tongue, which is specific to Kawasaki disease. The latter’s mucosal findings are distinctive, making this less accurate and incorrect compared to identifying Kawasaki disease as the cause of the tongue manifestation.

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Correct Answer is A

Explanation

Choice A reason: Half an aspirin with a viral infection poses a small Reye syndrome risk, warranting monitoring for symptoms like lethargy or vomiting. This aligns with pediatric safety guidelines, making it the best response to inform the mother while ensuring vigilance for the 9-year-old’s health.

Choice B reason: Nasal discharge and sneezing are unrelated to Reye syndrome, which involves neurological symptoms like stupor. Monitoring for lethargy or vomiting is correct, making this incorrect, as it lists irrelevant symptoms for the mother’s concern about Reye syndrome in her child.

Choice C reason: Admitting for observation overstates the risk, as a single half aspirin rarely causes Reye syndrome. Monitoring for specific symptoms is sufficient, making this alarmist and incorrect compared to the nurse’s balanced response to the mother’s concern about the viral infection.

Choice D reason: Downplaying the risk as unlikely ignores the potential, though rare, link between aspirin and Reye syndrome in viral infections. Monitoring for symptoms is prudent, making this dismissive and incorrect compared to advising vigilance for the 9-year-old’s safety post-aspirin use.

A. Determining the chief complaint. B. Interviewing the caregiver. C. Obtaining biographical data. D. Recording the health history.

Correct Answer is A

Explanation

Choice A reason: Determining the chief complaint identifies the primary reason for the visit, guiding the assessment and care plan for the child. This aligns with pediatric nursing triage principles, making it the prioritized step to ensure focused, efficient care during the first visit to the clinic.

Choice B reason: Interviewing the caregiver provides context but follows identifying the chief complaint, which directs the conversation. The complaint sets the visit’s focus, making this secondary and incorrect compared to prioritizing the reason for the child’s visit in the initial pediatric clinic appointment.

Choice C reason: Obtaining biographical data is administrative and less urgent than addressing the child’s health concern. The chief complaint drives the clinical encounter, making this less critical and incorrect compared to prioritizing the identification of the primary issue in the first clinic visit.

Choice D reason: Recording the health history is important but comes after understanding the chief complaint, which shapes the history-taking. Identifying the complaint ensures relevance, making this subsequent and incorrect compared to the prioritized step of determining the reason for the child’s visit.

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The nurse is collecting data from a caregiver, and the caregiver states that the child has had a “strawberry-colored tongue.” The nurse recognizes this as a manifestation of which disorder?

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Correct Answer is A

Explanation

A new client arrives for a first visit to the pediatric clinic. The nurse will prioritize which step in this appointment?

Correct Answer is A

Explanation

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